![Page 1: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/1.jpg)
Chapter 9. The Lean Enterprise
An Integrated Approach to Improving Quality and Efficiency
Daniel B. McLaughlinJulie M. Hays
Healthcare Operations Management
![Page 2: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/2.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-2
Chapter 9. The Lean Enterprise
• Definition of Lean• Types of waste• Kaizen• Value stream mapping• Tools
- Takt time, throughput time, five Ss, spaghetti diagrams, kaizen events, standardized work, jidoka, andon, kanban, SMED, flow and pull, heijunka, advanced access
• Lean Sigma
![Page 3: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/3.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-3
What Is Lean?
• Elimination of waste- Toyota Production System (TPS)
• Philosophy- Produce only what is needed, when it is
needed, with no waste
• Methodology- Determination of value added in the process
• Tools- Five Ss, kaizen event, standardized work, etc.
![Page 4: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/4.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-4
Types of Waste (Muda)
• Overproduction
• Waiting
• Transportation
• Inventory
• Motion
• Overprocessing
• Defects
![Page 5: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/5.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-5
Kaizen Philosophy
• Employee-led continuous improvement
• Five steps- Specify value- Map and improve the value stream- Flow - Pull- Perfection
• Even if it isn’t broken, it can be improved.
![Page 6: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/6.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-6
Value Stream Mapping
• Process map of the value stream
• Includes information processing and transformational processing
• Value-added steps: “Would the customer be willing to pay for this activity?”
• Non-value-added steps- Necessary- Unnecessary
![Page 7: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/7.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-7
Value Stream Mapping
Radiology LabHouse-keeping
PharmacySuppliesAnesthes-
iologySocial
Services
Porter
Stabilize
Incorrect patient forms
Rooms unavailable
Long wait after cleared to discharge
Education late
Slowturnaround
Patients
30-90 min
Admitting
1-3 hr
Triage
1-60 hr
Labor and
Delivery
20-80 hr
Post Partum
3 hr
Discharge
0-2 hr 1-3 hr 1-8 hr 1-5 hr
LOS
Rooms not available
Nurses’ time spent on non-patient care
Diagram created with eVSM software from
GumshoeKI, Inc., a Microsoft Visio
add-on.
![Page 8: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/8.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-8
Tools
• Takt time
• Throughput time
• Five Ss
• Spaghetti diagram
• Kaizen blitz or event
• Jidoka
• Andon
• Standardized work
• Kanban
• Single minute exchange of die (SMED)
• Flow
• Pull
• Heijunka
![Page 9: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/9.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-9
Takt Time
• The speed with which customers
must be served to satisfy demand for the service.
• Cycle time is the time to accomplish a task in the system.
• System cycle time is equal to the longest task cycle time in the system—the rate at which customers or products exit the system, or
“drip time.”
demand/dayCustomer
/day work timeAvailableTakt time
![Page 10: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/10.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-10
Throughput Time
• Time for an item to complete the entire process, which includes:- Waiting time- Transport time- Actual processing time
![Page 11: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/11.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-11
Riverview ClinicCycle, Throughput, and Takt Time
Diagram created with eVSM software from GumshoeKI, Inc., a Microsoft Visio add-on.
Move to examining room2 minutes
Patient check-in3 minutes
Nurse does preliminary exam
5 minutes
Physician exam and consultation
20 minutesVisit complete
Wait 15 minutes
Wait 15 minutes
Wait 10 minutes
![Page 12: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/12.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-12
Riverview ClinicCycle, Throughput, and Takt Time
• Patient check-in cycle time = 3 minutes.• System cycle time = cycle time for longest task =
physician exam and consultation = 20 minutes.• Throughput time = 3 + 15 + 2 + 15 + 5 + 10 + 20 =
70 minutes.
•
tient.minutes/paphysician 24 ent hours/patiphysician 0.4
aypatients/d 100hours/day 5 physicians 8Takt time
![Page 13: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/13.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-13
Riverview ClinicValue-Added Time
• Valued-added tasks:- Nurse preliminary exam- Physician exam and consultation
• Non-value-added steps, necessary:- Patient check-in
• Value-added time = 5 minutes (nurse preliminary exam) + 20 minutes (physician exam and consultation) = 25 minutes.
• Percentage value-added time = 25 minutes/70 minutes = 35 percent.
![Page 14: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/14.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-14
Five Ss
• Seiri (Sort)—Separate necessary from unnecessary items, including tools, parts, materials, and paperwork, and remove the unnecessary items.
• Seiton (Straighten)—Arrange the necessary items neatly, providing visual cues to where items should be placed.
• Seiso (Sweep)—Clean the work area.• Seiketsu (Standardize)—Standardize the first
three Ss so that cleanliness is maintained.• Shitsuke (Sustain)—Ensure that the first four
Ss continue to be performed on a regular basis.
![Page 15: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/15.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-15
Spaghetti Diagram
![Page 16: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/16.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-16
Kaizen Blitz or Event
• Determine and define the objectives• Determine the current state of the process• Determine the requirements of the process• Create a plan for implementation• Implement the improvements• Check the effectiveness of the improvements• Document and standardize the improved process• Continue the cycle
Plan
Check
Act
Do
![Page 17: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/17.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-17
Results of 175 Rapid Process Improvement
Weeks at Virginia Mason Medical Center
Source: Womack, J. P., A. P. Byrne, O. J. Fiume, G. S. Kaplan, and J.Toussaint. 2005. "Going Lean in Healthcare." Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Online information available at: http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm.
![Page 18: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/18.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-18
Standardized Work
• Written documentation of the way in which each step in a process should be performed
• Not a rigid system of compliance, but a means of communicating and codifying current best practices
• Massachusetts General Hospital care paths
![Page 19: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/19.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-19
Jidoka and Andon
• Jidoka is the ability to stop the process in the event of a problem.- Prevents defects from passing from one
step in the system to the next- Enables swift detection and correction of
errors
• Andon is a visual or audible signaling device used to indicate there is a problem in the process.
![Page 20: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/20.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-20
Kanban
Task 1Workstation
1
Task 2Workstation
2
Full Kanban
Customer Order
Full Kanban
Empty Kanban
Empty Kanban
Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.
![Page 21: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/21.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-21
Kanban
patientspatients echo
Signal
CT
Signal
Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.
![Page 22: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/22.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-22
Single Minute Exchange of Die (SMED)
• Used to reduce changeover or setup time, which is the time needed between the completion of one procedure and the start of the next procedure
• Steps- Separate internal activities from external
activities- Convert internal setup activities to external
activities- Streamline all setup activities
![Page 23: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/23.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-23
Flow and Pull
• Continuous or single piece flow—move items (jobs, patients, products) through the steps of the process one at a time without interuptions or waiting.
• Pull or just-in-time (JIT)—products or services are not produced until the downstream customer demands them.
• Heijunka—“make flat and level”; eliminate variation in volume and variety of “production”- Level patient demand
![Page 24: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/24.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-24
Advanced Access
• Patients are unable to obtain timely primary care appointments.
• Advanced access scheduling reduces the time between scheduling an appointment for care and the actual appointment.
• The goal is swift, even patient flow through the system.
![Page 25: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/25.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-25
Advanced AccessAdvantages
• Decreases no-show rates
• Improves patient satisfaction
• Improves staff satisfaction
• Increases revenue- Higher patient volumes- Increased staff and clinician productivity
• Promotes greater continuity of care- Increased quality of care- More positive outcomes for patients
![Page 26: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/26.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-26
Advanced AccessImplementation
• Advanced access challenges established practices and beliefs.
• Balance supply and demand:- Obtain accurate estimates of supply and
demand.- Reduce or eliminate backlog.- Minimize the variety of appointment types.- May need to:
• Adjust demand profiles.• Increase availability of bottleneck resources.
![Page 27: Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649c4f5503460f948f6667/html5/thumbnails/27.jpg)
Copyright 2008 Health Administration Press. All rights reserved. 9-27
Lean Sigma
Lean
Eliminate waste• Achieve flow
and pull
Six Sigma
Eliminate defects• Reduce
variation in processes
6666Lean and Six Sigma are focused on
continuous improvement of the system.